[PmbPhy (OP)]

I noticed that one of my fellow moderators suffers from chronic pain like I do. I thought she'd appreciate this article

https://www.statnews.com/2017/02/24/opioids-prescribing-limits-pain-patients/

It makes two excellent points

In effect, pain patients currently taking opioids long-term have become involuntary participants in an experiment, with their lives at stake.

To its credit, the guideline endorsed treating patients as individuals, not numbers.

Unfortunately doctors don't in general have a solid understanding of pain meds nor do they understand the meaning of statistics.

[PmbPhy (OP)]

Something that I've never understood is the reason for urine screens to test for cocaine when a person is being prescribed opiates. What I want to know is what the danger is of being on opiates when using cocaine. And please don't bore me with anecdotes about people dying from overdoses of the combination since I can provide just as many anecdotes about people who have used both at the same time a huge number of times and were fine.

I'm thinking about cocaine users with chronic pain who aren't prescribed pain-killers for that reason. It's inhumane to do nothing about the pain. Why? Because some people will kill themselves because the pain is intolerable. That's something I have first hand experience in. And I'm referring only to those situations when all else has failed. Thanks.

[chris]

Pete, cocaine and opiates are quite different types of drug; totally different family and mechanism.

[evan_au]

I listened to a podcast about the effects of medical marijuana on opiate consumption. They suggested that:
- For heroin, 5 times the effective dose will kill you
- For alcohol, 10  times the effective dose will kill you
- For marijuana, the ratio is even higher, ie death from overdose is very unlikely

In US states legalising medical marijuana, there has been a slight reduction in deaths from opiates - but this is a trend reversal, so this is promising.
- The main benefit seemed to be in substituting marijuana for the more dangerous (and more addictive) prescription opioid painkillers.
- They didn't have enough evidence from US states legalising recreational marijuana

When I raised the topic with some people who work in the pharmaceutical industry, they were very tight-lipped about it. I imagine that they have a very powerful economic incentive to fight medical marijuana as being "dangerous".

I have a relative who suffers from chronic pain, and has been on strong opiates for some time. I am in favor of doctors prescribing less dangerous medication, if it is effective.

Listen to the podcast (12 minutes), or click to read the transcript at: https://www.sciencefriday.com/segments/do-we-need-pot-to-fight-the-opioid-epidemic/

[RD]

What I want to know is what the danger is of being on opiates when using cocaine ...

Opiate-users add cocaine to combat its sedative effects : more euphoria, less unconsciousness.
The cocaine allows higher doses of opiate to be taken without losing consciousness,  but it wears-off quicker than the opiate,  then the user is particularly vulnerable to respiratory arrest via the opiate.

[ I read Carrie Fisher, whose cause of death was sleep-apnea, was positive for cocaine & heroin & more ]. 

[PmbPhy (OP)]

Pete, cocaine and opiates are quite different types of drug; totally different family and mechanism.

Yeah. I know. But that doesn't address my question. I.e. why put opiate users on a pain contract requiring urine screening?

Patients are never placed on pain contracts when taking meds like Xanax and you can die from a Xanax overdoes.

[chiralSPO]

I have a neighbor with severe chronic pain, who takes large amounts of very powerful opiates every day, and she gets drug tested routinely. But she ascribes this to her Dr. wanting to verify that she is in fact taking the drugs (instead of selling them), not necessarily to screen for other drugs in her system.

[RD]

... why put opiate users on a pain contract requiring urine screening?
Patients are never placed on pain contracts when taking meds like Xanax and you can die from a Xanax overdoes.

opiate-cocaine combo is a specific synergistic thing which opiate-users have been known to indulge in.

[PmbPhy (OP)]

I have a neighbor with severe chronic pain, who takes large amounts of very powerful opiates every day, and she gets drug tested routinely. But she ascribes this to her Dr. wanting to verify that she is in fact taking the drugs (instead of selling them), not necessarily to screen for other drugs in her system.

Pain contracts require patients to refrain from alcohol and recreational drugs. Violation means being taken off opiates.

Note: All opiates are powerful. Being on a high dose only means that their body has adapted to the lower dose and only a higher dose will work. I does not mean the patient is experiencing euphoria from them or is high. That's from personal experience and my "patients education" in opiates.

I'm concerned that this line of discussion is detracting from the real issue which I wanted to discuss. The refraining of giving opiates to chronic pain patients because a few of them abuse them.

What almost all doctors refuse to understand is that they can always require the opiates be distributed by a visiting nurse who keeps them in a safe and gives you one days worth. Or they can visit in the morning and night and watch you take the extended relief opiates like oxycontin or mscontin. Or even a pain pump.

[PmbPhy (OP)]

opiate-cocaine combo is a specific synergistic thing which people are known to indulge in.

What does that have to do with chronic pain patients use of opiates? In any case that doesn't address my question  which is why doctors care about that? I.e. does it mean a lower quality of life than living with no opiates and having the pain?

Besides, a visiting nurse can make sure that the opiates are taken exactly as prescribed.

[chiralSPO]

It may also have something to do with $$$$$$$$$$$

Drug testing in the US is a multi-billion dollar industry, and the handful of companies in charge spend an awful lot of money lobbying and contributing to campaigns of politicians (federal, state, and local), with the purpose of increasing compulsory drug testing. A large number of jobs will drug test before hiring, or will have "random" unannounced drug tests of employees. Some high schools in the US have implemented drug tests for their sports teams and clubs (not for deterring use of performance enhancing drugs, but for "keeping the children safe" from recreational drugs)--my understanding is that this has been shown to have no effect on drug use among high-schoolers, but it has deterred drug-using students from being members of sports teams and school orchestras etc. Some states require drug testing for welfare (again, likely not having much effect on drug use, just making users more desperate)

Another unanticipated effect of drug screening is that it pushes people to switch from relatively harmless drugs like cannabis, which can be detected for several weeks after the last use, to more dangerous drugs like alcohol, benzodiazepines, cocaine, and amphetamines, all of which can only be detected within a few days after the last use. (at least by tests of urine or saliva--more expensive hair tests can detect essentially everything that a person has used while the hair was growing)

[timey]

If you want to talk about inhumane treatment of pain patients:

My friend, having been diagnosed as having Weigners disease, was told she had 2 years to live.

16 years later, having been inadvertently infected with Hep C 10 years earlier by the hospital conducting her care for all those years, and having been prescribed a steadily increasing dose of opiates for the pain associated with her crumbling facial bones and neck vertebrae - guess what?
NHS brings in a zero tolerance policy regarding long term opiate prescription and during a hospitalization for a minor fall decided to put their Hep C patient into forced opiate withdrawal.

For those of you who are not familiar, a forced opiate withdrawal is life threatening for a Hep C patient.  Withdrawal exacerbates the Hep C.  The exacerbated Hep C causes damage to the liver, and my friend 'the Weigners patient' that was requiring the pain killer was left unable to ingest opiates.

I've never been so angry in all my life.  I printed the Hep C info off the net and gave it to the doctor responsible for the decision who couldn't find enough nurses to put between us before he slunk off.  I daresay he hadn't bothered to read my friends file that had built up over 16 years to require a trolley of it's own...
...but why would a trained doctor put a regular Hep C patient into forced withdrawal from a 16 year opiate prescription anyway?
Based on the fact that a forced withdrawal will exacerbate Hep C and destroy the liver, what benefit could there be in forcing an opiate withdrawal on a Hep C patient?

[PmbPhy (OP)]

If you want to talk about inhumane treatment of pain patients:

My friend, having been diagnosed as having Weigners disease, was told she had 2 years to live.

16 years later, having been inadvertently infected with Hep C 10 years earlier by the hospital conducting her care for all those years, and having been prescribed a steadily increasing dose of opiates for the pain associated with her crumbling facial bones and neck vertebrae - guess what?
NHS brings in a zero tolerance policy regarding long term opiate prescription and during a hospitalization for a minor fall decided to put their Hep C patient into forced opiate withdrawal.

For those of you who are not familiar, a forced opiate withdrawal is life threatening for a Hep C patient.  Withdrawal exacerbates the Hep C.  The exacerbated Hep C causes damage to the liver, and my friend 'the Weigners patient' that was requiring the pain killer was left unable to ingest opiates.

I've never been so angry in all my life.  I printed the Hep C info off the net and gave it to the doctor responsible for the decision who couldn't find enough nurses to put between us before he slunk off.  I daresay he hadn't bothered to read my friends file that had built up over 16 years to require a trolley of it's own...
...but why would a trained doctor put a regular Hep C patient into forced withdrawal from a 16 year opiate prescription anyway?
Based on the fact that a forced withdrawal will exacerbate Hep C and destroy the liver, what benefit could there be in forcing an opiate withdrawal on a Hep C patient?

Never assume that a doctor is intelligent merely because they're a doctor. I know that from an experience with a doctor I once had. She had the audacity to compare what I was taking for chronic pain with her experience taking a low dose Percocet.  My last exchange with a physicians assistant pissed me off big time because she claimed my dose was way too high, even though I've been on and off opiates for 12 years now. Dumb woman!!!

[PmbPhy (OP)]

If anybody would like to read a story which will break your heart then I recommend reading the following:

The Other Victims of the Opioid Epidemic June 1, 2017, Glod S.A. N Engl J Med 2017; 376:2101-2102
http://www.nejm.org/doi/pdf/10.1056/NEJMp1702188

[Karen W.]

Thanks Pete.. And everyone for the different information...

[PmbPhy (OP)]

The Other Victims of the Opioid Epidemic June 1, 2017, Glod S.A. N Engl J Med 2017; 376:2101-2102http://www.nejm.org/doi/pdf/10.1056/NEJMp1702188

I'm curious. Did anybody actually read that paper? I ask because I'm wondering whether posting such reference is a waste of my time or not.

[Karen W.]

I read the entire thing, and also thanked you in earnest.